The forgotten access gets a revival thanks to ultrasound, which offers good control with in-plane cannulation. You might find this gets you the best view on kids.
Yoffa’s supraclavicular approach
In 1952 Aubaniac described “A new route for venous injection or puncture: the subclavian route”, using the now familiar infraclavicular approach. In 1965 Yoffa described subclavian vein cannulation via a supraclavicular approach. Through several articles it seems to be just as effective and safe as the infraclavicular approach – but the supraclavicular route is very seldomly used and seems largely forgotten.
It can be used as a blind technique using anatomical landmarks. Yoffa’s original approach involves the clavisternomastoid angle, where the sternocleid attaches to the clavicle. Insertion of the needle 1 cm lateral and 1 cm posterior to this point, aiming slightly upwards and towards the contralateral nipple.
With ultrasound, everything feels safer. You can identify the internal jugular vein, the point where it meets the subclavian vein, and then the arch of the subclavian vein. This is easiest on children, where other access routes might be more difficult. With ultrasound, you can cannulate the vein in-plane, always seeing where your needle tip is placed, and where it is headed.
I can see the supraclavicular route as useful during surgery, where I have limited access to the patient. I usually use the internal jugular vein for that, but if the patient will be using the CVC long after the operation and he’ll be ambulating, it’s more comfortable to have a subclavian line. Also, if you for some technical reason can’t tilt the patient head down, the subclavian vein might be the bigger target, held open by surrounding tissue. It could also be a good technique to have in your arsenal as it’s described that swithcing between the supra- and infraclavicular route if one approach gives you problems yields a higher success rate.
There’s a good overview article of the supraclavicular approach found here:
Supraclavicular subclavian vein catheterization: the forgotten central line, West J Emerg Med, 2009.
As mentioned above, small children and neonates might be particularly well suited for the supraclavicular route. Central vein access can be challenging on these tiny creatures. The infraclavicular route offers a partly obscured ultrasound view, and internal jugular vein can be a moving target on a small neck. So, enter the ultrasound guided supraclavicular approach. In the junction of the internal jugular and subclavian vein, you can align the linear ultrasound probe with the clavicle, and get a longitudal view of the arch of the subclavian vein. And visualise the pleura directly underneath it. You’re trying to fit your US probe in a pretty small area, so you’ll want a hockey stick probe – some even advocate an endocavitary probe on the smallest people, to fit the small footprint. You’re milage might vary.
Thanks to Thanks to Dr. Jean-Paul Mission at Hôpitaux Pédiatriques de Nice in France for uploading the videos. Another one can be found here.